Provider Demographics
NPI:1891722120
Name:WOLCOTT, PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:WOLCOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 W ATEN RD STE 2
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9805
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:790 W ORANGE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:760-353-8858
Practice Address - Fax:760-545-0248
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55463174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G554631Medicaid
CA00G554631Medicaid
CAG55463AMedicare PIN